In 2020, American healthcare and social services professionals had the most illnesses and injuries of any industry. They saw a 249 percent increase compared to previous years.
If you’re an orthopedic surgeon, you could be at risk. Do you have long-term disability insurance?
Have you suffered a disabling illness or injury that prevents you from practicing? Keep reading to learn how to get the help you need.
About 40 percent of claims get denied, rated, or have exclusions applied.
Long Term Disability (LTD) Plan for Physicians
The Employee Retirement Income Security Act (ERISA) was established in 1974. It sets minimum standards for many private industry health and retirement plans. The goal is to protect the plan participant’s interests as well as their beneficiaries.
ERISA classifies these plans as follows.
“Own Occupation”
This type of policy often defines “own occupation” in narrow terms. For example, a medical doctor must have a specified specialty or sub-specialty. This includes orthopedic surgeons.
Disability means that your medical issues make it impossible to perform your job. This applies to your primary occupation. If you meet this condition, you should receive benefits.
“True own-occupation” policies let you receive disability benefits and still earn an income. Many individuals may not know that, if able, they can work in another specialty or profession.
So, physicians who are recovering from an injury or illness may still see patients as able. You may perform surgeries, conduct research, teach, or complete administrative tasks. This all depends on your individual level of disability.
“Any Occupation”
An “any occupation” policy requires the policyholder to prove that you can’t perform any job. They usually include occupations that fit the person’s education, experience, and training.
It’s more challenging to meet these policies’ standards. The injury or illness must be so severe that you can’t do any type of work. They’ll deny your claim if you work even part-time at a job with a much lower wage.
“Any Gainful Employment”
With this type of policy, you must prove that you can’t perform “any gainful employment.” They define this as work that pays you at least part of the salary you earned before.
How Long Does LTD Plan Coverage Last?
Most LTD policies start paying after you’ve been unable to work for 90 days. From then, you receive benefits while you still can’t perform your duties. This may range from six to 34 months.
Many physicians think they’re covered by their hospital’s group disability policy. Yet, group coverage often doesn’t fully replace your income.
It also isn’t portable. What if you decide to move around or work locum tenens? You may no longer have coverage under the group policy.
This is why it’s important to consider buying your own LTD insurance. Also, explore the company’s riders that pertain to your practice specialty.
What’s Involved in Filing an LTD claim?
ERISA LTD claims get approved or denied based on the insurer’s ruling on your level of impairment. They evaluate your “limitations” and “restrictions.”
A limitation means the activities you’re able to do but at a lesser intensity, frequency, or duration. Restrictions describe the activities that you can’t perform at all.
The LTD claim process involves several steps.
Provide Proof of Disability
Physicians don’t normally use these terms in the same way as insurance companies. Thus, it’s key for evaluating providers to know what insurers look for and provide evidence. If your doctor simply states that you’re disabled, your claim will get denied.
Each policy creates its definition of disability. This often involves language in separate “riders” purchased by the customer.
When determining disability, insurers look for complex legal proof. They want clear links between your condition and impairment. For example, if a person loses feeling in their dominant hand but can still move it, they can work.
Yet, if this happens to an orthopedic surgeon, they’re unable to execute all their duties. These specialties rely on precise assessments and performing tedious procedures.
Insurance policies may or may not fall under ERISA oversight. Unfortunately, there’s no consistent, uniform standard established for determining disability.
The truth is, you’re at their mercy. Thus, it’s important to consult with an attorney and be diligent in filing claims.
The Disability Claim Investigation Process
To start the process, you, your doctor, and your employer will complete several forms. The insurer uses this information to collect information about your work background. They compare prior functional abilities to your current level.
These forms explore the following:
- Medical symptoms and conditions
- Medical treatments you’re receiving
- Medications you’re taking
- Hobbies and daily activities
- Your specialty’s responsibilities and duties
- Work experience and education
This is when they determine your restrictions and limitations. It’s key to comply with the insurance company’s requests during their investigation. A lack of cooperation could result in a denial of your claim.
Review of Your Medical Records
The insurance company will complete a thorough review of your medical records. They’re looking for factual, objective evidence to support your claim. Examples include radiology and blood test results.
Remember, you must give the insurer permission to access your medical record. You want them to see all your tests and diagnostic studies that support your diagnosis. Thus, sign HIPAA release forms or send them full copies of your records.
An insurance company physician may conduct the record review and suggest work restrictions. In other cases, your claim gets examined by an insurance adjuster.
Request for Independent Medical Evaluation
Some insurers request that you have an independent medical examination (IME). Or they may ask you to undergo a functional capacity evaluation (FCE). You won’t have to pay for these additional visits.
The IME focuses on your disability. The IME doctor will provide a report of their findings and may include work restrictions.
An FCE involves a series of objective, fact-based tests to evaluate your ability to work. The FCE examiner then files a detailed report describing your physical capabilities. Most of the time, this will recommend restrictions for work.
Always attend all requested appointments. Make sure you’re honest during the visit so that your report is valid. Inaccurate reports can lead to denial of benefits.
Vocational Analysis
First, they review your medical records and exams. Then they describe any work restrictions needed. This may involve both mental and physical job constraints.
The next step is a vocational analysis. This serves to decide if your restrictions allow you to work.
The insurer will develop a Summary Plan Description (SPD) defining your disability. Then the insurer compares your SPD to work you’ve done or other jobs in the national economy. If they think you’re able to work, they may deny your claim.
Provide a Decision
It can take months to receive the insurer’s decision. All denied insurance claims must explain why you weren’t approved. Denial letters must also tell you how to appeal their decision.
Denied Long Term Disability Claim: What’s the Next Step?
If you receive a letter of denial, contact an expert ERISA lawyer immediately. The appeals process often has strict filing rules and deadlines. It takes time to develop an appeal and you want your attorney to have the best advantage.
Remember, your lawyer has experience with denied insurance claims. They’ll guide you in providing the best evidence to support your case. This involves reviewing insurer files, requesting more information, and preparing written arguments.
How to Successfully Appeal Denied LTD Claims
The appeals process is often legally complex. Thus, your attorney will represent your best interests and get the best outcome. Here is an overview of key steps for success.
File Accurate Documents
Always file requested documents on time. Demonstrate honesty, transparency, and accuracy in all reporting. Avoid minimizing or exaggerating your symptoms.
Choose Your Doctor Carefully
Choose a physician for your exam and documentation that knows about disability claims. They must understand the insurer’s definitions of limitations and restrictions. All documents and tests must support these definitions of disability.
Additional Documentation
Did you know that you can also include evidence from co-workers, family members, and others? This can help paint a complete picture of your disability.
Unfair Claims Practices
Watch out for unfair claims practices when insurance companies focused on CPT (Current Procedural Terminology) to determine ortho occupational duties. CPT is for purposes of billing insurance companies for healthcare, not for determining occupational duties.
Do You Need Help with Long-Term Disability Claims? Call Us at 866-816-3171.
Are you facing a denied long-term disability claim? Jonathan M. Feigenbaum, Esquire’s firm, has expertise in appealing insurance benefit denials. We’ll guide you through the entire process using our proven winning strategy.
We’ll fight for your rights. Our team understands disability, life, healthcare, and long-term care insurance claims. We’ll cut through the red tape, navigate roadblocks, and give you peace of mind. Request a complimentary consultation today to learn how we can help
